Prevalence and risk factors for spousal violence among women attending health care centres in Alexandria, Egypt

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H.M. Mamdouh,^1,2 H.M. Ismail,¹ I.F. Kharboush,¹ M.M. Tawfik,¹ O.G. El Sharkawy,¹ M. Abdel-Baky ¹ and H.N. Sallam ^1,3

معدّل انتشار وعوامل اختطار عنف الأزواج لدى النساء المراجعات لمراكز الرعاية الصحية في الإسكندرية، مصر

هبه ممدوح، هناء إسماعيل، إبراهيم خربوش، مي توفيق، أمينه الشرقاوي، محمد عبد الباقي، حسن سلام

الخلاصـة: أجرى الباحثون مسحاً مستعرضاً للتعرف على معدلات انتشار عنف الأزواج والعوامل التي تؤثر عليه، لدى 3271 إمرأة سبق لهن الزواج، ممن يراجعن 12 مركزاً من مراكز رعاية صحة الأسرة تم اختيارها عشوائياً في محافظة الإسكندرية. وقد أبلغ أكثر من ثلاثة أرباع المشاركات في الدراسة (%77) عن معاناتهن من عنف الأزواج خلال حياتهن الزوجية. وقد كان العنف العاطفي هو النمط الأكثر شيوعاً (%71)، تلاه العنف الجسدي (%50.3) ثم العنف الجنسي (%37.1)، والعنف الاقتصادي (%40.8). وتؤكد الدراسة المعدل المرتفع لانتشار عنف الأزواج في جميع الطبقات الاقتصادية والاجتماعية. ويشير التحليل التحوُّفي اللوجستي إلى ترابط عنف الأزواج مع حجم العائلة الكبير، والطلاق أو الانفصال، وانخفاض مستوى التحصيل التعليمي المنخفض للزوج، واعتياد التدخين لدى الزوج وتعاطيه لمواد الإدمان، والوضع النفسي للزوج، وسابقة التعرُّض لعنف جسدي أثناء المراهقة. وهذا المعدل المرتفع لعنف الأزواج يوضِّح الحاجة الملحَّة لتصدِّي الحكومة والمجتمع المدني لهذه القضية التي تعرقل إحراز التقدُّم نحو المرامي الإنمائية في مصر.

ABSTRACT We conducted a cross-sectional survey to determine the prevalence of, and factors affecting, spousal violence among 3271 ever-married women attending 12 randomly selected family health centres in Alexandria Governorate. More than three-quarters of the participants (77%) reported experiencing spousal violence during their marital life. Emotional violence was the most common type reported (71.0%), followed by physical (50.3%), economic (40.8%) and sexual (37.1%) violence. The study confirms the high prevalence of spousal violence across all socioeconomic strata. Logistic regression analysis indicated large family size, divorce or separation, low educational attainment of husband, smoking habit and drug use in husband, husband’s psychological status and history of exposure to physical violence during adolescence were associated with spousal violence. This high rate of spousal violence highlights the urgent need for government and civil society to address the issue, which hinders progress toward Egypt’s development goals.

Prévalence et facteurs de risque de la violence conjugale chez des femmes consultant dans des centres de soins de santé à Alexandrie (Égypte)

RÉSUMÉ Nous avons mené une enquête transversale afin de déterminer la prévalence de la violence conjugale et des facteurs associés chez 3271 femmes ayant déjà été mariées et consultant dans 12 centres de santé familiaux sélectionnés aléatoirement dans le Gouvernorat d'Alexandrie. Plus des trois quarts des participantes (77 %) ont indiqué avoir souffert de violence conjugale au cours de leur vie maritale. La violence psychologique était la plus fréquente (71,0 %), suivie par la violence physique (50,3 %), puis la violence économique (40,8 %) et enfin la violence sexuelle (37,1 %). L'étude confirme la prévalence élevée de la violence conjugale dans toutes les strates socioéconomiques. Une analyse de régression logistique a révélé que la violence conjugale était associée à l'appartenance à une famille nombreuse, à un divorce ou une séparation, à un faible niveau d'études du mari, à des habitudes de tabagisme et de consommation de drogues du mari, à l'état psychologique du mari, et à des antécédents d'exposition à la violence physique pendant l'adolescence. Ce taux élevé de violence conjugale souligne l'urgente nécessité pour le gouvernement et la société civile de s'attaquer au problème, qui freine la progression de l'Égypte vers ses objectifs de développement.

¹Alexandria Regional Centre for Women’s Health and Development; ²Department of Maternal and Child Health, High Institute of Public Health; 3Department of Obstetrics and Gynaecology, University of Alexandria, Alexandria, Egypt (Correspondence to H.M. Mamdouh: This email address is being protected from spambots. You need JavaScript enabled to view it.)

Received: 09/08/11; accepted: 04/10/11

EMHJ, 2012, 18(11): 1118-1126

Introduction

Violence against women is a major public health problem worldwide; it kills, tortures and maims women, affecting them not only physically, but also psychologically, sexually and economically [1]. Violence against women is present in every country, cutting across boundaries of culture, class, education, income, ethnicity and age. Violence against women is one of the most pervasive human rights violations, denying women’s and girls’ equality, security, dignity and self-worth and their right to enjoy fundamental freedoms [1].

The terms “domestic violence” and “spousal violence” are often used interchangeably and refer to husbands as the perpetrators, the most common case [2]. Domestic violence, a more general term, can also include abuse of other family members such as children [3]. Domestic violence is now widely recognized as a serious human rights and public health problem that concerns all sectors of society [4]. The global dimensions of this violence are alarming, as highlighted by studies on its incidence and prevalence [1]. A World Health Organization (WHO) multi-country study on violence against women indicated that 15%–71% of ever-married women world-wide are victims of domestic violence at least once in their marital lives [5].

Until now, patriarchal norms continue to relegate many Egyptian women to a subordinate position relative to men. Women are particularly at risk of spousal abuse in societies where there are marked inequalities between men and women, and rigid gender roles and cultural norms [6].

Certain characteristics of women and their husbands reinforce the subordinate position of women in the family, and therefore put some women at greater risk of experiencing marital violence [6]. Research has indicated several related factors that could contribute to, or protect from, violence against women [3,7]. These include individual, household, community and societal factors. Individual factors include woman’s level of education and/or employment, delayed marriage, her control of economic resources and her involvement in household decision-making. Positive household factors include high household wealth, compatibility between husband and wife in education and economic resources and having fewer children. Community factors include urban versus rural domicile, poverty and community norms and practices regarding gender relations and equality. Societal factors refer to the norms and policies in the society at large that could contribute to, or protect from, violence against women.

A high prevalence of domestic violence among ever-married females presenting to outpatient clinics in Cairo, Egypt was described by Bakr and Ismail in 2005 [8]. This study highlighted a much higher prevalence (88.4%) of domestic violence in women attending health care facilities in Egypt than that reported by the Egypt Demographic and Health Survey of 2005 (47.4%)[9]. The high rate of domestic violence reported in health facilities compared to that reported in the household surveys [9,10] gave the justification for conducting a study on violence against women in Alexandria, targeting women attending health facilities. Therefore, the present study among women attending family health centres in Alexandria, Egypt aimed to provide new data on the prevalence of all forms of spousal violence by current or previous husband, and to identify factors that may either protect women or put them at risk of spousal violence.

Methods

This survey was conducted, using a cross-sectional design, in the period October 2009–June 2010.

Target population

The sample consisted of ever-married women attending publicly funded family health centres distributed in the 7 districts of Alexandria.

Sampling and sample size

With a precision of 2.5%, a 95% confidence interval, a design effect of 2 and a 28% prevalence of violence against women [9], the minimum estimated sample size was calculated, using Open­Epi, version 2, at 3100 women. A total A total of 3500 ever-married women were approached to compensate for missing data; 3271 women agreed to participate and were interviewed, i.e. 6.6% refused to participate.

The sample design for the survey included 12 family health centres representing both urban and rural residence. The centres were selected randomly from a list of centres working under the newly introduced Family Health Model. These family health centres provide low-cost services for families, including women from different socioeconomic strata, in many disciplines, including preventive and curative services. The sample was distributed according to the total population of each district.

Participants eligible for the study were ever-married women who completed visits in physician-led clinics for any reason and who were not accompanied by their husbands (to ensure safe disclosure of the spousal abuse experience). Women were selected by choosing every fourth woman as they were leaving the clinic. Interviews took place in the clinic. Data collection was done daily, until the desired sample size was reached at each centre.

Data collection

After reviewing the available national and international literature, a structured interview questionnaire was developed. Questions on all types of spousal abuse were modified and reviewed to be culturally relevant. Arabic translation of the instrument was developed and it was checked by forward then backward translation by qualified translators. The questionnaire was designed to obtain detailed information on sociodemographic background, women’s and husbands’ characteristics, the prevalence of all forms of violence, the forms of violence ever-married women had ever experienced during their marital relationships with their current husband or most recent husband. Over the study period of 5 months, trained female data collectors interviewed eligible women to complete the pre-designed questionnaire.

The survey explored various types of spousal violence, specifically, physical, sexual, emotional and economic spousal violence. When a woman confirmed that she had experienced at least 1 of these acts of violence, it was considered in the analysis that she had experienced the indicated form of violence. Physical violence questions asked about being slapped or beaten, or the husband throwing things to harm the wife, being pushed or grasped by force, being kicked or dragged, being strangled or burned on purpose and being threatened with a knife or gun or actually having such a weapon used on them. Sexual violence questions referred to a wife being forced to have sex against her will, being forced to have sex when she was ill, being forced to have sex during menses, being hit during sex, being told hurtful words during sex and being forced to do things or be in positions she finds insufferable during sex. Emotional spousal abuse included being insulted, being ignored or treated indifferently, being threatened with harm, either to herself or someone she cares about (e.g. her children), being threatened with having to leave house or be divorced, being insulted or humiliated in front of other people, being deliberately frightened, and being forbidden to go out or take part in social activities. Economic abuse focused on being forced to work (if she did not want to work) and the husband not working, husband refusing to spend money on home demands (when he had money), husband controlling (in a bad way) how she spent her own money (e.g. spending it on his pleasure), being forced to give husband all the money she earned, being forced to borrow money from people, and being forced to beg every time she asked for money.

Data analysis

Data entry and analysis were carried out over a 5-month period using SPSS, version 16. Univariate analysis was performed with the Chi-squared test whenever applicable. Logistic regression analysis was used to identify variables that were significantly related to spousal violence. The outcome variable was ever exposure to any spousal violence with women’s and their husband’s characteristics taken as covariate (independent) variables.

Ethical considerations

After explaining the study objectives and procedures, women who agreed to participate were interviewed alone in specially arranged settings in the health units to ensure confidentiality during the interviews. Written informed consent was obtained from the participants at the start of the interview (oral in the case of illiterate women). In addition, at the start of each module, each respondent was read a statement to inform her that her answers were completely confidential.

Interviews lasted an average of 35 minutes (range 25–45 minutes).

Results

Sociodemographic characteristics

Women’s age ranged from 16 years to 68 years, mean 36.6 (standard deviation 9.8) years. Regarding education level, 38.5% of the participants were illiterate or could just read and write and 30.5% of them had secondary education. Most of the participants (87.6%) were currently married; 73.6% reported being married before the age of 25 years. More than two thirds of the participants were housewives (71.8%), while only 5.6% of them had professional jobs. Nearly half of the surveyed women (56.9%) had a family size of 4–5 persons. About half the participants (51%) reported having a monthly family income of 400 to < 900 Egyptian pounds (US$ 1 = 5.93 Egyptian pounds).

Just over half the husbands were married before age 30 years (55.4%). As for the husbands’ education, 37.4% were illiterate or just could read and write, 29% had secondary education or technical diploma, and 17.4% were university graduates with higher degrees. Just over half of the husbands were manual workers (55,0%), with 5.1% of the participants reporting that their husbands were not working. The majority of the husbands were smokers (66.0%), 12.4% were drug addicts, and 4.2% were alcoholics. Nearly, 4% of participants reported that their husbands were ever treated for psychological illness.

Prevalence of spousal violence

More than three-quarters of our participants (2519 women) had experienced spousal abuse of any type during their marital life. About half the women who reported ever experiencing spousal violence were subjected to 2–3 types of violence (49%), with 28% suffering all 4 types of spousal abuse (data not shown). Emotional abuse was the most common type of spousal abuse reported (2322 women, 71%).

Approximately 70% of the women suffered from emotional abuse during their marital life (Table 1) and 10% of these reported that their husbands ever used abusive language to insult them and make them feel bad. Nearly 90% of women who ever experienced emotional abuse said that they experienced multiple forms of emotional abuse (data not shown).

Half the women who participated in this study reported experiencing some form of physical violence by their husbands at some point in their marital life. The most common forms of physical violence reported were slapping (44.7%) and beating (30.5%) (Table 1).

More than 1 in 3 women (37.1%) ever experienced some form of sexual violence. The most common forms were: being forced to have sex against their will (25.4%) and being forced to have sex when they were ill (23.3%) (Table 1).

Overall, 43% of women reported economic abuse in any period during their marital lives; 27% of these said their husband forced them (under threat of violence) to beg for money (Table 1).

Factors associated with women’s exposure to spousal violence

Characteristics of women and their husbands which were associated with spousal violence are illustrated in Table 2 and Table 3 . Spousal violence was most prevalent among women aged 25–< 35 years (P < 0.05) (Table 2). Spousal violence varied significantly among women who had different levels of education and different types of occupation. Women who had never attended school and those who were involved in manual work or inferior jobs such as janitor or maid were at greater risk of experiencing spousal violence than their counterparts. Divorced/separated women, those who were married before age 20 years and women who were married for 5–10 years showed greatest exposure to spousal violence (P < 0.05). Women who lived in larger families, those with a low monthly family income and those who had a history of exposure to severe physical violence since age 15 years reported the highest frequency of spousal violence (P < 0.05). Prevalence of spousal violence against the woman was lower when the couple had similar educational attainment than for their counterparts (Table 2).

Husband’s age at marriage seems to have no association with the risk of spousal violence (Table 3). There was an association between husbands’ habits and women’s exposure to spousal violence: a statistically significantly higher proportion of women reported suffering from spousal violence if their husbands were smokers, drank alcohol or were addicted to drugs. Over 90% of the husbands who were being treated for any psychological illness were violent (93.2%) (Table 3).

In the logistic regression analysis, women whose husbands were addicted to drugs were over 10 times more likely to experience violence than their counterparts (Table 4). Divorced/separated were about 6 times more likely to experience violence than married women. Women with a history of exposure to physical violence since the age of 15 years had a 3-fold increase in the incidence of spousal violence compared with those who had no such exposure.

Discussion

In this survey among women attending family health facilities in Alexandria, Egypt, around 77% reported some form of spousal violence; the most common type was emotional abuse. Our data together with the world-wide literature confirm that domestic violence is a universal phenomenon existing in all communities [5,7,11].

According to a 2005 survey, 36% of Egyptian women had ever experienced some form of marital violence (emotional, physical, and/or sexual) by their current/most recent husband [9]. A survey published in 2009 indicated a much higher proportion of Egyptian women (62.6%) reporting exposure to emotional violence by their husbands than physical violence (28%) [10]. The women who participated in our study in Alexandria reported experiencing higher rates of spousal violence than those reported in both the 2005 and 2009 household surveys [9,10]. The rate of intimate partner violence documented in primary care settings varies widely; different studies have reported 22%–90% of women seen in primary care facilities had suffered such violence [8,12,13].

The methodological differences and data collection methods used in the household studies [9,10] make comparability with our findings difficult. Several factors may be involved; the most important is that women in our study may have felt more comfortable speaking because the interviews were conducted in health facilities and not in their homes (which may affect women’s willingness to disclose abuse). Additionally, confidentiality can be more easily assured in health care facilities than in households. There is often a culture of silence around the topic of domestic violence, which makes the collection of data particularly challenging, especially when the women are surrounded by their relatives. Confidentiality concerns, embarrassment, and fear of escalating violence were the most important barriers to abuse disclosure reported by women in a previous study conducted in the United States of America [12].

Generally, women visiting the publicly-funded health facilities in Alexandria Governorate belong to lower socioeconomic groups, and thus were more vulnerable to domestic violence. Low socioeconomic status was associated with more violence in many settings in the WHO multi-country study and in an Iranian review of nationally representative surveys [5,13]. Our study included a larger, more in-depth set of questions regarding all types of violence compared with some other studies on violence among Egyptian women [9,10].

The levels of all forms of spousal violence reported in the current study were high, with emotional abuse being the most frequent form. It is possible that emotional abuse may be considered part of the Egyptian culture: people shout, swear and insult each other more easily than in many other cultures, but physical violence is not so common, possibly because of lower levels of alcohol and drug addiction in the abusive men [14]. In addition, the present study included a comprehensive list of questions on emotional abuse that might have resulted in this high rate. The rate of emotional abuse reported in our study (71%) was at the upper end of a range previously reported in the 2005 WHO study (20%–75% across all countries) [5].

It is more difficult for women to disclose experiences of sexual violence than physical violence. Likewise, to talk about sexual violence within marriage in such a religious and conservative culture as that in Egypt is not regarded as very appropriate. Nevertheless, 37% of the participants disclosed that they had ever experienced any form of sexual violence. In Egyptian society, cultural and religious norms support a husband’s right to sex regardless of a wife’s feelings, therefore many women do not consider having sex against their will as abuse. However, a sizeable proportion of the women in our study (25.4%) considered having sex against their well as a type of sexual abuse

Examining the characteristics of women who experience violence and the contexts in which they live helps to identify some of the common risk factors for violence. Among our sample, certain characteristics of women and their husbands may reinforce the subordinate position of women in the family and, therefore, put some women at greater risk of experiencing violence. It is important to recognize that many of these characteristics are interrelated. For instance, persons with higher levels of education are more likely to have higher income or to marry partners with a high level of education [15]. We found that large family size, divorce or separation between the couples, low educational attainment of the husbands, husbands’ habits such as smoking and drug use, husbands’ psychological status and a history of exposure to physical violence during adolescence were the correlates of spousal violence among the participants in our survey. Consistent with the our findings, secondary analysis of the 2005 Egyptian Demographic and Health Survey data revealed that partner’s education, respondent’s education, work status and place of residence were significantly associated with marital violence [16,17]. Studies from all over the world identified several sociodemographic factors that might increase the likelihood of women exposure to intimate partner/spousal abuse [5,16,18–21]. These included such factors as spousal educational difference, duration of the marriage, wealth quintile, partner’s education, respondent’s education and work status, and place of residence

Education has been shown to be a source of empowerment for women [22,23]. The more highly educated participants in our survey reported the lowest levels of spousal abuse. The same pattern was noted for husbands’ education. However, husband’s education seems to have more influence: it remained significant in the logistic analysis while women’s education level did not. It seems that husbands’ education helps to change their attitude towards gender norms. Analysis of the 2005 survey data suggested that female education is most likely to help safeguard women against spousal violence when the couple share similar years of schooling [16]. In addition, in most settings in the WHO multi-country study, the greater the education of the women and their partners, the less the reported spousal violence [5].

In our study, women living in larger families were twice as likely to have experienced spousal violence compared with their counterparts. Having many children places economic and emotional stress on a marriage and increases a woman’s likelihood of experiencing abuse. In her in-depth analysis of spousal physical abuse among a sample of women from Minya, Egypt, Yount found that household wealth was negatively associated with physical abuse [24].

The logistic model also indicated that divorced women were about 5 times more likely to report suffering from spousal violence than currently married women. It may be that spousal violence is the leading cause of the divorce in first place, or that women are freer to speak about their previous husbands than their current ones. In addition, recall bias, which is directly related to age and current marital status of the women [25], can also partially explain why younger or currently married women experience more violence. Data from international surveys on violence against women showed that women who were divorced or separated reported higher rates of violence than women who were currently married [5,18].

Unsurprisingly, the logistic model showed that husbands’ unfavourable habits such as smoking and drug use were correlated with women’s ever exposure to spousal violence. Drug use was mentioned as a risk factor for domestic violence in previous studies [18,26,27].

Policies and programmes aimed at addressing gender-based violence of any kind, including spousal violence, must address the roots of the problem—cultural practices that discriminate against women—and correct the imbalance in rights and power-sharing between males and females in Egyptian families and society. Outdated and patriarchal behaviours and laws that support male domination need to be abolished, and the status of girls and women needs to be raised in both the family and society. Interventions to address violence against women must be carried out across multiple sectors because of the legal, social, cultural, and health implications.

Conclusion

This study confirms the high prevalence of all forms of spousal abuse among a representative sample of women attending publicly funded health centers in Alexandria, Egypt. Spousal violence is widespread and the rates are alarming, highlighting the urgent need for government and civil society to address the issue and end this scourge that hinders progress toward Egypt’s development goals. Empowering women and raising their social status seem to be the key strategies for eliminating spousal violence among this group of Egyptian women.

Acknowledgement

This study was part of a larger survey carried out by the Alexandria Regional Centre for Women’s Health and Development. It was funded by the Ford Foundation.

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